https://journals.lww.com/annalsplasticsurgery/pages/currenttoc.aspx
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https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Surgeon_Sleep_Deprivation,_Surgical_Complications,.1.aspx
No abstract available]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00001https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Basic_Microvascular_Anastomosis_Simulation_Hub.2.aspx
Early year's plastic surgery trainees are faced with a large choice of microsurgery courses to select from. In the context of dwindling study budgets and busy on-call rotas, the pressure to select a high yield course that delivers value for money is of paramount importance.
The Basic Microvascular Anastomosis Simulation Hub Microsurgery Course is a GBP £600 (US $790) 5-day 40-hour course based at Barts and The London School of Medicine and Dentistry increasing in popularity among junior trainees to fit this brief.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00002https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Labiaplasty___A_24_Month_Experience_in_58.3.aspx
Background
Because there has been a great raise in the interest of this type of surgery in our area, we decided to study if there were any differences among our patients and also to review our results.
Objective
The purpose of this study was to review our experience with labiaplasty. We assessed surgical complications and quality outcomes and compared surgical results according to maternal parity.
Methods
We conducted a retrospective chart review of all cases of primary or secondary labia minora reduction surgery performed by the same surgeon from January 2014 to December 2015. We recorded patient demographics, sexual activity, parity, and presurgical and postsurgical quality of life, as well as surgical technique and complications.
Results
During the study period, we performed 58 labia minora reduction procedures. The average patient age was 32.16 years. Among the patients, 50% were single, 65.52% sexually active, and 62.07% nulliparous. A wedge excision was performed in 75.8% of cases. A complication occurred in 12.06% of cases, usually owing to underresection. The surgical experience was rated very good or excellent by 96.55% of patients. Women with children reported greater satisfaction with their surgical outcome on our postoperative questionnaire. We identified no statistically significant outcome differences according to surgical technique.
Conclusions
Labiaplasty is safe and shows high rates of overall satisfaction. Women with children reported greater postoperative satisfaction than women who had never given birth.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00003https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Labia_Majora_Augmentation_Combined_With_Minimal.4.aspx
Background
All the labia minora reduction techniques fail to treat the other component of the abnormally increased labia minora to majora ratio: the labia majora atrophy. The purpose of this study is to describe a technique of female genitalia beautification, which combines labia majora augmentation and conservative labia minora reduction.
Methods
The hypertrophied labia minora were first treated by a conservative inferior wedge excision with a superior flap. The conservative excision was done to obtain labia minora that would still protrude beyond the labia majora because it will be masked by the augmentation of the labia majora. Labia majora augmentation was done by autologous fat transplantation. The newly augmented labia majora completely masked the conservatively reduced labia minora.
Results
Twenty-one patients underwent surgery for labia majora augmentation and labia minora reduction. One patient (4.7%) had a small separation of the labial edge postoperatively that resolved with no additional interventions. There was no flap necrosis or infections. No patient reported pain or sexual dysfunction. Seventeen patients (81%) were satisfied or very satisfied with their results.
Conclusions
Labia majora augmentation combined with a conservative labia minora reduction is an appealing procedure because it enhances the global aspect of the female genitalia while reducing the labioplasty complications.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00004https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Flap_Mastopexy_in_Autologous_Breast.5.aspx
Background
Techniques in breast reconstruction have significantly advanced the possibility to create more natural and aesthetically appealing breasts. Despite thorough preoperative planning and vigilant operative technique, symmetry remains a concern for select patients who have undergone autologous breast reconstruction. Although symmetry procedures of the contralateral breast have been well described in the literature, little has been published regarding secondary revision in the autologous reconstructed breast, leaving uncertainty as to the appropriate timing and technique for revision procedures that will not hinder the viability of the flap. In this article, we provide an effective, reproducible and safe method of mastopexy after autologous breast reconstruction.
Methods
A retrospective review of all patients undergoing autologous breast reconstruction by a single surgeon between 2007 and 2014 was performed. Patients who underwent mastopexy after autologous breast reconstruction were included. Patient characteristics, type of reconstruction, staging of procedures, secondary operations, and complications were recorded.
Results
Ten patients with asymmetric autologous breast reconstruction underwent flap mastopexy in 1 or both breasts. Indications for mastopexy included asymmetry resulting from immediate loss of autologous flaps, unilateral fat necrosis, scarring after mastectomy flap necrosis, excess ptosis, and volume asymmetries. No flap loss, fat necrosis, or nipple loss occurred after flap mastopexy.
Conclusions
The autologous mastopexy technique is a useful option in secondary refinement procedures for breast reconstruction. It provides a reliable and predictable method to adjust the inframammary fold, increase projection, and address excess ptosis. It has a low complication rate and can be safely and reliably performed as early as 3 months after initial reconstruction.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00005https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/An_Evaluation_of_the_Choice_for_Contralateral.6.aspx
Background
Rising contralateral prophylactic mastectomy rates are a subject of national concern. This study assessed (1) factors critical to patients when deciding on contralateral prophylactic mastectomy and (2) patients' quality of life related to concerns about recurrence after unilateral or bilateral breast reconstruction.
Methods
Patients with stage 0 to III breast cancer who underwent unilateral mastectomy or contralateral prophylactic mastectomy and breast reconstruction at a single institution between 2000 and 2012 were identified. Demographic and clinical data were extracted by chart review. Women's fears about breast cancer recurrence were assessed using the Concerns About Recurrence Scale, and motivational factors for contralateral prophylactic mastectomy were identified using the Decisions for Contralateral Prophylactic Mastectomy Survey.
Results
Survey responses were received from 157 patients (59%) who underwent unilateral reconstruction and 109 (41%) who underwent bilateral reconstruction. The top 3 reasons for choosing contralateral prophylactic mastectomy were (1) decreasing the risk of contralateral breast disease (97%), (2) peace of mind (96%), and (3) improved survival (93%). Women who chose contralateral prophylactic mastectomy reported significantly greater overall fear and worry compared with the unilateral group, specifically, greater fears of dying and worries about adequately fulfilling roles of daily life (P < 0.05).
Conclusions
Despite no proven survival benefit, women chose contralateral prophylactic mastectomy primarily to optimize oncologic outcomes. Among breast reconstruction patients, women who underwent contralateral prophylactic mastectomy had greater anxiety and overall fear of breast cancer recurrence compared with those who chose unilateral mastectomy. These findings are important to consider when counseling women contemplating contralateral prophylactic mastectomy.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00006https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Low_Versus_High_Vacuum_Suction_Drainage_of_the.7.aspx
Background
Placement of suction drainage in submuscular pockets is routinely performed in breast reconstruction. Days of drain permanence (DDP) are associated with hospital stay and related health care costs. The aims of this study are to retrospectively compare data related to DDP and total drainage volume between high and low vacuum suction drainage groups and to identify correlations with patient or surgery-related factors.
Methods
We retrospectively analyzed data of 100 patients undergoing immediate or delayed breast reconstruction with expanders and implants. We considered 2 groups depending on suction pressure applied by 2 different surgical teams: group A (number, 50 patients) with high vacuum suction and group B (number, 50 patients) with low vacuum suction.
Results
Days of drain permanence was not significantly different between group A and group B (P = 0.451). The same was found for total drainage volume (P = 0.183). The distribution of DDP was statistically different only between patients with or without intraoperative bleeding in group A (P = 0.005) and smoking or nonsmoking patients in group A (P = 0.045). Statistical significance was kept in multivariate regression.
Conclusions
There is no significant difference in DDP and total drainage volume using low or high vacuum suction drainage in breast reconstruction. The only factors affecting drainage permanence were intraoperative filling of expander, smoking, and intraoperative bleeding. Therefore, we can reduce the DDP, avoiding overfilling of expander and using of high vacuum suction in nonsmoking patients and in patients with significant intraoperative bleeding.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00007https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Skin_Burn_Associated_With_Photochemotherapy.8.aspx
Objective
psoralen and ultraviolet A (PUVA) phototherapy (PT) has become a standard treatment for several severe skin diseases. Photosensitization is done by oral psoralen intake. In minor cases, PUVA can lead to skin changes like erythema and hyperpigmentation. However, it can also lead to severe burn injuries when exposed to extensive UV light. This makes the treatment in a burn center inevitable.
Methods
We report the clinical observation of a 38-year-old man presenting with an extensive burn injury caused by sun tanning after PUVA PT.
Conclusions
There are just few cases of extensive burns induced by PUVA PT. Prevention becomes manifest in patient information, correct calculation of dosage, evaluation of photosensitivity, and close observation. In cases of severe burn injuries, patients should be referred to a burn center for optimal conservative treatment. Surgical intervention is usually not necessary.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00008https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Antegrade_Intramedullary_Pinning_in_Subacute_Fifth.9.aspx
Purpose
The purposes of this study were to evaluate the efficacy of antegrade intramedullary pinning performed for neck fractures with angulations of over 30 degrees after failed conservative treatment during the subacute phase and to compare the radiologic and clinical results with those of acute fractures with angulations of over 30 degrees treated via the same procedure.
Methods
Seventy-three patients with a fifth metacarpal neck fracture were admitted to our institute between January 2010 and April 2015. Among them, 26 patients with an acute fracture (group 1) and 27 patients with a subacute fracture after failed conservative treatment who met the inclusion/exclusion criteria were investigated. After surgery, improvements in angulation and shortening, visual analog scale score for postoperative pain, Disabilities of the Arm, Shoulder, and Hand score, active range of motion, and grip strength were evaluated and compared.
Results
The mean durations of surgery from injury were 4.92 and 32.74 days in groups 1 and 2, respectively, with a significant difference (P < 0.001). The preoperative amounts of angulation were 44.91 and 45.89 degrees, and the amounts of preoperative shortening were 3.31 and 3.44 mm, respectively, with no significant difference (P > 0.05). At the final follow-up, the angulation had definitively improved compared with before surgery in both groups (P < 0.001, both). However, there was a slight significant difference in terms of the residual angulation of 3.35 and 5.56 degrees in groups 1 and 2, respectively (P = 0.02). Preoperative shortening was restored in both groups (P < 0.001, both) and the final state of residual shortening were similar (P = 0.06). The final visual analog scale scores, Disabilities of the Arm, Shoulder, and Hand scores, range of motion, and grip strength were all satisfactory in both groups without any significant difference.
Conclusions
The failed treatment group, which had been predicted to obtain proper union through the initial use of conservative treatment, provided an adequate indication for noninvasive antegrade pinning. In addition, the current study suggested that closed reduction/immobilization remains a primary recommendation for angulated metacarpal neck fracture as long as careful observation is conducted if progression of the reduced fracture toward dorsal angulation is suspected.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00009https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Step_Cut_Lengthening__A_Technique_for_Treatment_of.10.aspx
Reconstruction of a tendon defect is a challenging task in hand surgery. Delayed repair of a ruptured flexor pollicis longus (FPL) tendon is often associated with tendon defect. Primary repair of the tendon is often not possible, particularly after debridement of the unhealthy segment of the tendon. As such, various surgical treatments have been described in the literature, including single-stage tendon grafting, 2-stage tendon grafting, flexor digitorum superficialis tendon transfer from ring finger, and interphalangeal joint arthrodesis. We describe step cut lengthening of FPL tendon for the reconstruction of FPL rupture. This is a single-stage reconstruction without the need for tendon grafting or tendon transfer. To our knowledge, no such technique has been previously described.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00010https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Splinting_After_Ear_Reconstruction__A_Stepwise_and.11.aspx
Background
Long-term postoperative splinting plays a role in the prevention of contracture of the grafted skin after a second-stage ear reconstruction. The scar retraction could lead to an unfavorable aesthetic outcome. Splinting could play a role to overcome or prevent the loss of projection and the obliteration of the sulcus.
Material and Methods
We have defined the characteristics of an ideal long-term splint and present a stepwise clinical protocol for the fabrication of an ethylene-vinyl acetate splint. The splint was applied to all patients included in a prospective study on the postoperative splinting regime. Ethylene-vinyl acetate has proved its safety and longevity in dental prosthetics.
Conclusions
Patient compliance was optimal, and no allergic reactions, pressure sores, or skin necrosis were reported. The splint is self-retaining and light weight. Because of its transparent color, it can be easily camouflaged. A stepwise clinical protocol for the fabrication of a low-cost patient-specific ear splint is presented.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00011https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Three_Dimensional_Analysis_of_Airway_Change_After.12.aspx
Introduction
LeFort III midface advancement using the distraction technique became the standard method for the correction of various craniofacial syndromes accompanied by the midface retrusion. Midface hypoplasia is known to be related to the imbalance in facial aesthetics, malocclusion, and the airway problem. This study aimed to evaluate the change in airway volume after performing a LeFort III midface advancement with the distraction techniques.
Patients and Methods
Between April 2008 and February 2013, 7 patients aged 5 to 7 years underwent standard LeFort III osteotomy, followed by distraction with a rigid external distractor with or without internal distractor. The degree of advancement of the midface and the airway volume were evaluated with 3-dimensional computed tomography scans and the 3-dimensional software.
Results
The average latent period was 3.57 days. The average manual distraction distance was 17.55 mm for 3.82 weeks. The consolidation period ranged from 3 to 7 months. Changes between the preoperative and postoperative airway volumes were remarkable. The average preoperative postpharyngeal airway volume was 5649.33 mm3 compared with an average postoperative airway volume of 7403.44 mm3. Therefore, the average postpharyngeal airway space increased by a remarkable 32.78%.
Conclusions
This investigation revealed that the LeFort III midface advancement using distraction could increase postpharyngeal airway space by approximately 33% when the midface is advanced by approximately 18 mm. This method could be used as a future reference for LeFort III midface advancement with distraction.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00012https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Versatility_of_the_Medial_Femoral_Condyle_Flap_for.13.aspx
Background
The medial femoral condyle (MFC) flap has become a popular choice for treatment of small bony defects. We aim to describe outcomes after MFC flap treatment of upper and lower extremity osseous defects and test the null hypothesis that no factors influence risks for nonunion, increased time to union, and complications.
Methods
A retrospective chart review was performed on all patients undergoing MFC free vascularized bone flaps by the senior author between May 2010 and March 2016. Preoperative, intraoperative, and postoperative data were collected.
Results
We identified 29 patients for inclusion (22 upper and 7 lower extremity reconstructions) treated with the MFC flap for diagnoses including long bone nonunion, avascular necrosis (AVN), or AVN with nonunion. Mean postoperative follow-up was 56 weeks. The average patient was 38 years old (range = 17–61 years) and had undergone 1.5 previous failed surgeries. Union was achieved in 86% of patients at a mean of 15.8 weeks (83% at 17.9 weeks for the scaphoid). No patient with lunate AVN progressed. There were no intraoperative flap complications or bone flap loss, but 28% underwent additional unplanned surgical procedures. We identified previous surgery as a risk factor for delayed union but did not observe significant risk factors predictive of nonunion or complications requiring unplanned reoperation.
Conclusions
Extremity reconstruction using the MFC corticocancellous flap results in a high rate of union yet minimal donor morbidity for a challenging patient cohort. Previous surgery was a risk factor for increased time to union.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00013https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/One_Barrel_Microsurgical_Fibula_Flap_for.14.aspx
Various methods for reconstructing large femur bone defects after tumor resection have been introduced. In this study, we reviewed the clinical outcomes of using a 1-barrel free vascularized fibular graft (FVFG) protected by a lateral locking plate for large femoral defects not involving the knee joint.
Between August 2007 and August 2013, we treated 7 patients with large femoral bone defects after tumor resection. The mean age of the patients was 19 years (range, 12–36 years), and 3 were women. All defects were free of infection before the procedure. Femoral bone defects were reconstructed using a 1-barrel FVFG protected by a lateral locking plate. The mean bone defect size was 10.5 cm (range, 6–16 cm). We reviewed clinical outcomes at the last follow-up.
All patients survived beyond the last follow-up; the mean follow-up period was 54 months (range, 26–100 months). Two patients sustained stress fractures of the FVFG, but the lateral locking plate protected the fractured graft until in situ bone healing obtained. Mean time to bone union of both host-graft junctions was 24 months (range, 18–31 months). The mean Musculoskeletal Tumor Society score (%) was 85.8% (range, 80–95%).
A 1-barrel FVFG protected by a lateral locking plate maintained a stable graft-host bone construct, successfully leading to bone healing, even in cases of stress fractures of the graft, and appears to be a good option for large femur bone defects.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00014https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Use_of_Vascularized_Sural_Nerve_Grafts_for_Sciatic.15.aspx
Background
Vascularized nerve grafting is normally associated with a good outcome, but can be difficult to use for nerve reconstruction in patients with long defects of the sciatic nerve given the graft thickness. We report 3 cases of large defect sciatic nerve reconstruction using the bilateral sural nerves of the lower legs harvested together with the fascia and lesser saphenous vein to form a vascularized flap.
Methods
The subjects were 3 patients who required the reconstruction of a 10-cm or longer segment of the sciatic nerve. Priority was given to restoring sensation in the plantar region such that reconstruction of the sensory nerves corresponding to the tibial region.
Results
Two patients were followed up for long term. There was some persistent perceptual deficit in the foot, minimal protective sensation had been achieved.
Conclusions
We were able to selectively reconstruct the sensory nerves to achieve sensation in the soles of the feet by using sural nerve grafts from both legs. As the prognosis for the underlying condition in cases necessitating this procedure is often poor, the costs and benefits of reconstruction should always be weighed carefully for each individual patient.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00015https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Assessment_of_the_Effect_of_Autograft_Orientation.16.aspx
Purpose
Given no definite consensus on the accepted autograft orientation during peripheral nerve injury repair, we compare outcomes between reverse and normally oriented autografts using an advanced magnetic resonance imaging technique, diffusion tensor imaging.
Methods
Thirty-six female Sprague-Dawley rats were divided into 3 groups: sham—left sciatic nerve isolation without injury, reverse autograft—10-mm cut left sciatic nerve segment reoriented 180° and used to coapt the proximal and distal stumps, or normally oriented autograft—10-mm cut nerve segment kept in its normal orientation for coaptation. Animals underwent sciatic functional index and foot fault behavior studies at 72 hours, and then weekly. At 6 weeks, axons proximal, within, and distal to the autograft were evaluated using diffusion tensor imaging and choline acetyltransferase motor staining for immunohistochemistry. Toluidine blue staining of 1-μm sections was used to assess axon count, density, and diameter. Bilateral gastrocnemius/soleus muscle weights were compared to obtain a net wet weight. Comparison of the groups was performed using Mann-Whiney U or Kruskal-Wallis H tests to determine significance.
Results
Diffusion tensor imaging findings including fractional anisotropy, radial diffusivity, and axial diffusivity were similar between reverse and normally oriented autografts. Diffusion tensor imaging tractography demonstrated proximodistal nerve regeneration in both autograft groups. Motor axon counts proximal, within, and distal to the autografts were similar. Likewise, axon count, density, and diameter were similar between the autograft groups. Muscle net weight at 6 weeks and behavioral outcomes (sciatic functional index and foot fault) at any tested time point were also similar between reverse and normally oriented autografts.
Conclusions
Diffusion tensor imaging may be a useful assessment tool for peripheral nerve regeneration. Reversing nerve autograft polarity did not demonstrate to have an influence on functional or regenerative outcomes.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00016https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Outcomes_of_Ventral_Hernia_Repair_With_Concomitant.17.aspx
Purpose
Combined ventral hernia repair and panniculectomy (VHR/PAN) is controversial, and the safety profile including anticipated complications has been questioned. We present a retrospective case series review of patients from the University of Maryland Medical Center to help surgeons counsel patients on the risks and benefits of this procedure.
Methods
A retrospective database was collected using current procedural terminology codes for VHR/PAN. The patient-specific variables that were studied include the following: sex, body mass index (BMI), smoking, diabetes, chronic obstructive pulmonary disease, cirrhosis, immunosuppression, length of operation, acute incarcerated hernias, hernia size and location, mesh size and location, pannus weight, concomitant component separation, use of negative-pressure wound therapy, intestinal violation, follow-up duration, ventral hernia working group, history of bariatric surgery, previous hernia repair, skin dehiscence, skin necrosis, chronic wound, surgical site infection, seroma, hematoma, fascial dehiscence, hernia recurrence, unplanned return to operating room, and medical complication. Both univariate and multivariate analyses were performed to determine which factors affected the complication outcomes.
Results
There were 106 patients with an average age and BMI of 53 years and 39, respectively. Fifty-eight patients (54.72%) had at least 1 surgical site occurrence. Twenty-three patients (21.70%) had at least 1 repair failure. Twenty-eight patients (26.42%) had an unplanned trip back to the operating room. Seventeen patients (16.04%) had at least 1 medical complication.
Conclusions
The risk factors associated with developing complications are higher BMI, longer operating time, larger mesh size, larger hernia size, component separation, use of biologic mesh, chronic obstructive pulmonary disease, and intestinal violation. The use of negative-pressure wound therapy decreased complication rates, and patients with a previous hernia repair seemed to benefit the most from having a combined VHR/PAN. However, when compared with previous reports of VHR alone, VHR/PAN does seem to increase wound complications and reoperation rates.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00017https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/The_Perineal_Turnover_Perforator_Flap__A_New_and.18.aspx
Background
Extralevator abdominoperineal excision (ELAPE) is increasingly used to treat locally advanced low rectal cancer as it has been related to superior oncological outcomes than traditional abdominoperineal excision.
However, ELAPE also has been associated with high perineal wound morbidity rates as it creates a larger perineal cavity than standard abdominoperineal excision. This greater defect, along with the effects of preoperative chemoradiation on wound healing, makes uneventful perineal reconstruction post-ELAPE a real challenge for the plastic surgeon.
In this paper, the authors present a new technique for perineal reconstruction post-ELAPE, using a perforator, islanded, turnover, de-epithelialized local flap (perineal turnover perforator [PTO] flap).
Methods
The PTO flap is raised based on perforators from internal pudendal artery. The flap is based on the concept that thick gluteal dermis can act as an “autologous dermal vascularized” substitute for the excised pelvic floor muscles, whereas the bulk of its subcutaneous tissue is used to obliterate dead space.
Fourteen patients underwent perineal reconstruction using this approach. Patients' demographics, neoadjuvant chemoradiotherapy, histopathology, duration of surgery, follow-up, and complications were analysed retrospectively.
Results
Median operating time was 49 minutes. There were no flap, donor site, or major wound complications. One patient had superficial skin dehiscence, and one patient developed perineal hernia. None of the patients developed chronic perineal pain.
Conclusions
The PTO flap is a quick, simple yet safe and reliable option for perineal reconstruction after ELAPE that offers many advantages over the heretofore used reconstructive techniques including primary closure, myocutaneous flaps, and biological meshes.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00018https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/A_New_Option_for_the_Reconstruction_of_Primary_or.19.aspx
Background
Owing to the high recurrence rates of ischial pressure sores, surgeons should consider the possibility of future secondary flap surgery during flap selection. The purpose of this article is to present a new surgical option for the reconstruction of primary or recurrent ischial pressure sores using a simple hamstring-adductor magnus advancement flap and direct closure.
Methods
After horizontal fusiform skin excision, complete bursa excision and ischiectomy were performed. The tenomuscular origin of the adductor magnus and the conjoined tenomuscular origin of the biceps femoris long head and semitendinosus were isolated and completely detached from the inferior border of the ischial tuberosity. They were then advanced in a cephalad direction without detachment of the distal tendon or muscle and securely affixed to the sacrotuberous ligament. The wound was directly closed without further incision or dissection.
Results
Twelve ischial pressure sores (6 primary and 6 recurrent; 12 patients) were surgically corrected. The follow-up period was 12 to 65 months. All patients healed successfully without early postoperative complications, such as hematoma, seroma, infection, wound dehiscence, or partial necrosis. Late complications included wound disruption 5 weeks after surgery that spontaneously healed in 1 case and recurrence 3 years later in another case.
Conclusions
The new surgical option presented herein, which involves hamstring-adductor magnus advancement flap and direct closure, is a simple and reliable method for providing sufficient muscle bulk to fill the dead space and proper padding to the bone stump while preserving the main vascular perforators and pedicles as well as future surgical options.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00019https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Universal_Applicability_of_the_Furlow.20.aspx
Background
Questions persist regarding the general applicability of the Furlow palatoplasty technique, and thus, widespread adoption of its use has been uneven. This study describes a consecutive, nonselective series of primary Furlow palatoplasties. Highlighted is the unique fact that plastic surgical residents functioned as the primary surgeon for all steps of all procedures throughout the series.
Methods
A retrospective review was undertaken of all primary palatoplasties performed under the direction of the senior surgeon between December 2005 and April 2012. A stringent requirement for speech outcome reporting was patient age at the latest assessment of older than 4.5 years. Other measured parameters included fistula rate, incidence of secondary surgery, and procedure duration.
Results
Seventy-five patients were included in this study. Nasal resonance was rated as “normal” in 56.1% of the patients and “mildly hypernasal or better” in 95.1% of the patients. Articulation errors were detected in 14.6% of the patients, and symptoms related to nasal air emission were detected in 4.9% of the patients. Overall fistula rate was 5.3%. The following associations were detected: (1) Veau cleft type and procedure duration, P = 0.001; (2) resident year of training and procedure duration, P = 0.009; (3) developmental delay and resonance score, P = 0.002; (4) patient age at surgery and resonance score, P = 0.025; and (5) presence of syndrome and resonance score, P = 0.036.
Conclusions
This nonselective series of consecutive Furlow palatoplasty procedures demonstrates that plastic surgical residents are able to match best published clinical results performing the entire procedure under the close supervision and guidance of an assisting surgical mentor.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00020https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Factors_Associated_With_Late_Surgical.21.aspx
Background
Surgical cancellations that occur within 1 day of the procedure (ie, late cancellations) disrupt the efficiency of the operating room. The aim of the present study was to identify the factors associated with late cancellations in a tertiary pediatric surgical practice.
Methods
We reviewed the medical records of patients treated by plastic and oral surgery services at our institution from 2010 to 2015. We collected data pertaining to the timing and reasons for cancellation. Reasons for cancellation were retrospectively classified by the investigators as either “preventable,” “possibly preventable,” “unpreventable,” or “undocumented.” We also measured the frequency of cancellations based on type of surgery.
Results
Of 10,730 scheduled operating room cases, 444 (4.1%) were cancelled within 24 hours of the procedure. Sixty-seven percent (297/444 cases) were cancelled on the same day as the planned procedure, and the remaining cases were cancelled the day prior after 1 PM. Forty-two percent of cancellations were deemed preventable, and 45.3% of cases were deemed possibly preventable. The majority of procedures were cancelled because of illness (44%), inadequate fasting (9%), and parental inconvenience (7%). The highest frequency of cancellation was found in skin lesion (36%) followed by dentoalveolar (14%) and cleft lip and palate (12%) cases.
Conclusions
In our study, most late surgical cancellations were preventable or possibly preventable. The timing of the cancellation is important because those that occur near the scheduled procedure time disallow adequate and timely redistribution of operating room resources and personnel. Analyzing and addressing the preventable and possibly preventable causes outlined in this study will significantly improve efficiency and patient access.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00021https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Monitoring_of_Myocutaneous_Flaps_by_Measuring.22.aspx
Introduction
In surgery, certain defects require reconstruction with a microsurgical flap. The free flap failure rate varies between 2% and 5%. Vascular thrombosis is the most frequent complication and represents 15% to 73% of failures. The success rate of salvage therapy is greater when salvage surgery is early. Currently, clinical monitoring is the criterion standard but many noninvasive or minimally invasive techniques have been developed to improve early diagnosis of complications of vascular thrombosis. The aim of our experimental study was to compare clinical assessments with measurements of capillary glycemia and lactatemia during the monitoring of free flaps.
Materials and Methods
Myocutaneous latissimus dorsi flaps with skin paddles were created in pigs under general anesthesia. For each animal, 2 flaps were created (right and left) using the same technique. Four groups were made: group 1 (no flap ligation: control group), group 2 (flap with permanent ligation of the artery), group 3 (flap with permanent ligation of the two veins), group 4 (flap with transient ligation of the artery and 2 veins for 1 hour). The postoperative monitoring protocol consisted of monitoring the clinical, biological (glucose and lactate), and histological parameters.
Results
Eight animals were operated on and sixteen flaps were created. Each flap was clinically and biologically tested 25 times. Clinical, biological, and histological monitoring showed significant variations between the groups. The analysis of variance of capillary glycemia and lactatemia showed statistically significant difference between control group and group 2 (P < 0,0001), group 3 (P < 0,0001), or group 4 (P < 0,0001). There were no histological abnormalities after transient ligature at different times contrary to permanent ligature.
Discussion-Conclusion
Measuring capillary levels of lactate and glucose associated with clinical monitoring may shorten the time to diagnosis of flap failure. Ultimately, this will save lives and achieve better functional and aesthetic results.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00022https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Extracorporal_Shock_Wave_Therapy_Enhances_Receptor.23.aspx
Background/Objectives
Loss of skin flaps due to deteriorated wound healing is a crucial clinical issue. Extracorporal shock wave therapy (ESWT) promotes flap healing by inducing angiogenesis and suppressing inflammation. The receptor for advanced glycation end-products (RAGEs) was identified to play a pivotal role in wound healing. However, to date, the role of RAGE in skin flaps and its interference with ESWT are unknown.
Methods
Caudally pedicled musculocutanous skin flaps in RAGE−/− and wt mice were treated with low-dose extracorporal shock waves (s-RAGE−/−, s-wt) and analyzed for flap survival, histomorphologic studies, and immunohistochemistry during a 10-day period. Animals without ESWT served in each genotype as a control group (c-RAGE−/−, c-wt). Statistical analysis was carried out by repeated-measures analysis of variance.
Results
Flap necrosis was significantly reduced after ESWT in wt animals but increased in RAGE-deficient animals. Morphometric differences between the 4 groups were identified and showed a delayed wound healing with dysregulated inflammatory cells and deteriorated angiogenesis in RAGE−/− animals. Furthermore, spatial and temporal differences were observed.
Conclusions
The RAGE controls inflammation and angiogenesis in flap healing. The protective effects of ESWT are dependent on intact RAGE signaling, which enables temporary targeted infiltration of immune cells and neoangiogenesis.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00023https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/A_Surgical_Approach_to_the_Harvest_of_the.24.aspx
Background
Extremity lymphedema is a pathological condition resulting from absence of lymph nodes and disease of lymphatic vessels, often due to oncologic clearance of lymph nodes. In recent years, vascularized lymph node transfer has become a rapidly emerging method of lymphatic reconstruction shown to lead to lymphatic regeneration. In particular, lymphatic flaps based on the submental artery have shown good results with its favorable donor site and available nodes. The lymph nodes here are in close relation to the submandibular gland and require careful dissection around and through the gland for safe harvest. We studied this region of the neck and describe the blood supply to the lymph nodes, their variable positions in relation to the gland, and our technique of dissecting through the submandibular gland while keeping the lymph nodes' hilar blood supply intact.
Methods
We dissected 2 cadaver heads (4 sides of the neck) to study the submandibular and submental lymph nodes, where to locate them in relation to the submandibular gland and how best to dissect through the submandibular gland for access while keeping the hilar supply intact. We applied this knowledge in 6 clinical cases and provide a brief description of our “through-the-gland” dissection technique.
Results
The submandibular lymph nodes may lie (1) superficial and posterior to the gland, (2) between the superficial and deep parts of the submandibular gland, or (3) anteriorly and submental. They are classified as superficial, deep, and submental, respectively. The through-the-gland dissection technique gave the surgeon improved access and exposure to the lymph nodes. It also facilitated safer dissection because their hilar blood supply is well visualized.
Conclusions
The through-the-gland technique of harvesting vascularized submandibular lymph node flaps is a safe technique that allows the surgeon to clearly identify and preserve blood supply of lymph nodes.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00024https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Vascularized_Composite_Allotransplantation_of_the.25.aspx
Background
Surgical options for the unreconstructable elbow are limited to arthrodesis, total arthroplasty, or osteoarticular allograft reconstruction. Each of these options is limited by severe functional impairment and/or high complication rates. Vascularized allotransplantation of the elbow joint has the potential to mitigate these complications. In this study, we describe our technique for harvesting the elbow for vascularized joint transplantation and demonstrate the flap's vascularity using contrast angiography.
Methods
Anatomical studies were used to design and harvest a vascularized elbow joint flap pedicled on the brachial vessels in 10 cadaveric arms. Diaphyseal blood supply is provided by 3 nutrient arteries, and periarticular supply arises from the various collateral arteries of the arm and recurrent arteries of the forearm. The brachialis and supinator, and their respective nerves, were included as functional muscles because of their intimate association with critical vasculature. Tendinous insertions of the biceps and triceps, as well as the flexor/pronator and extensor origins, were preserved for repair in the transplant recipient. Both lateral arm and radial forearm flaps were preserved to aid in soft tissue inset as well as vascular/immunologic monitoring. Contrast angiography of each dissected specimen was performed to assess the location of the nutrient vessels and assess flap vascularity, as indicated by filling of the critical extraosseous and endosteal vessels.
Results
Angiographic imaging of 10 specimens demonstrated that this flap dissection preserves the nutrient endosteal supply to the humeral, radial, and ulnar diaphysis, in addition to the critical extraosseous arterial structures perfusing the elbow joint and periarticular tissues. From proximal to distal, these arteries are the musculoperiosteal radial, posterior branch of the radial collateral, inferior ulnar collateral, recurrent interosseous, radial recurrent, and the anterior and the posterior ulnar recurrent.
Conclusions
Vascularized composite allotransplantation of the elbow joint holds promise as a motion and function preserving option for young, high-demand patients with a sensate and functional hand, who would otherwise be limited by the restrictions of total elbow arthroplasty or fusion. In this study, we propose a flap design and technique for harvest and also offered vascular imaging–based evidence that this flap is adequately vascularized.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00025https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/The_Use_and_Delivery_of_Stem_Cells_in_Nerve.26.aspx
Outcomes following peripheral nerve injury remain poor despite the regenerative capacity displayed by the peripheral nervous system. Current therapies are limited and do not provide satisfactory functional recovery in a multitude of cases. Biomaterials have decreased the need for nerve autograft across small nerve gaps in small-caliber nerves, but the lack of a cellular substrate presents a limiting factor to the effectiveness of this therapy. Schwann cells are the supportive cells in the peripheral nervous system and play an integral role in the physiological response and regeneration following nerve injury. Limitations to autologous Schwann cells include donor site morbidity during harvesting, limited expansion capability, and finite source. Stem cells are multipotent or pluripotent cells with self-renewing capabilities that show promise to improve functional recovery following nerve injury. Differentiation of stem cells into supportive Schwann cells could provide additional trophic support without the disadvantages of autologous Schwann cells, providing an avenue to improve existing therapies. A variety of stem cells have been evaluated in animal models for this clinical application; the current options, along with their clinical feasibility, are summarized in this article.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00026https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Breast_Reconstruction__A_Century_of_Controversies.27.aspx
Breast cancer treatment has dramatically changed over the past century. Since Halsted’s first description of radical mastectomy in 1882, breast reconstruction has evolved slowly from being considered as a useless or even dangerous procedure by surgeons to the possibility nowadays of reconstructing almost any kind of defect. In this review on the development of breast reconstruction, we outline the historical milestone innovations that led to the current management of the mastectomy defect in an attempt to understand the economic, social and psychological factors, which contributed to slow down its acceptance for several decades.]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00027https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Optimizing_Radiotherapy_for_Keloids.28.aspx
No abstract available]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00028https://journals.lww.com/annalsplasticsurgery/Fulltext/2018/04000/Modified_Subcutaneous_Buried_Horizontal_Mattress.29.aspx
No abstract available]]>Sun, 01 Apr 2018 00:00:00 GMT-05:0000000637-201804000-00029